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    Subclavian vein thrombosis with internal jugular vein extension in an Australian rules football player

    John WP Wong, Fiona WY Lai and Ian Wilson
    Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00335
    Published online: 15 October 2018

    Clinical record


    • 1 Royal Melbourne Hospital, Melbourne, VIC
    • 2 Northeast Health Wangaratta, Wangaratta, VIC
    • 3 Rural Health, University of Melbourne, Shepparton, VIC


    Correspondence: johnwpwong@gmail.com
    Competing interests:

    No relevant disclosures.

    • 1. Esmon CT. Basic mechanisms and pathogenesis of venous thrombosis. Blood Rev 2009; 23: 225-229.
    • 2. Bernardi E, Pesavento R, Prandoni P. Upper extremity deep venous thrombosis. Semin Thromb Hemost 2006; 32: 729-736.
    • 3. Lindblad B, Tengborn L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae. Eur J Vasc Surg 1998; 2: 161-165.
    • 4. Alla VM, Natarajan N, Kaushik M, et al. Paget–Schroetter syndrome: review of pathogenesis and treatment of effort thrombosis. West J Emerg Med 2010; 11: 358-362.
    • 5. Héron E, Lozinguez O, Alhenc-Gelas M, et al. Hypercoaguable states in primary upper-extremity deep vein thrombosis. Arch Intern Med 2000; 160: 382-386.
    • 6. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res 2006; 117: 609-614.

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      Australia is responding to the complex challenge of overdiagnosis

      Ray Moynihan, Alexandra L Barratt, Rachelle Buchbinder, Stacy M Carter, Thomas Dakin, Jan Donovan, Adam G Elshaug, Paul P Glasziou, Christopher G Maher, Kirsten J McCaffery and Ian A Scott
      Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.01138
      Published online: 15 October 2018

      An Australian alliance of clinical, consumer, research and public organisations is emerging to tackle overdiagnosis

      Overdiagnosis is now a health challenge recognised across many nations.1 Debates about its definition continue, but in short, overdiagnosis happens when health systems routinely diagnose people in ways that do not benefit them or that even do more harm than good.2 Overdiagnosis is unwarranted diagnosis, leading to harms from unnecessary labels and treatments and to the waste of health care resources that could be better spent dealing with genuine needs. To manage overdiagnosis and the sustainability of the health system more broadly, reversing the harm of too much medicine is becoming a health care priority, demanding effective responses in policy and practice. In Australia, a new alliance is developing a national plan to deal with this problem.


      • 1 Centre for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD
      • 2 University of Sydney, Sydney, NSW
      • 3 Cabrini Institute, Melbourne, VIC
      • 4 Monash University, Melbourne, VIC
      • 5 University of Wollongong, Wollongong, NSW
      • 6 Consumers Health Forum of Australia, Canberra, ACT
      • 7 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
      • 8 George Institute for Global Health, University of Sydney, Sydney, NSW
      • 9 Princess Alexandra Hospital, Brisbane, QLD
      • 10 University of Queensland, Brisbane, QLD


      Correspondence: RayMoynihan@bond.edu.au
      Competing interests:

      All authors were involved in planning the 2017 National Summit on Overdiagnosis.

      • 1. Welch G, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health. Boston: Beacon; 2012.
      • 2. Carter SM, Degeling C, Doust J, Barratt A. A definition and ethical evaluation of overdiagnosis. J Med Ethics 2016; 42: 705-714
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      • 4. Hoffman JR, Cooper RJ. Overdiagnosis of disease: a modern epidemic. Arch Intern Med 2012; 172: 1123-1124.
      • 5. Vaccarella S, Franceschi S, Bray F, et al. Worldwide thyroid-cancer epidemic? The increasing impact of overdiagnosis. N Engl J Med 2016; 375: 614-617.
      • 6. Glasziou P, Moynihan R, Richards T, Godlee F. Too much medicine; too little care. BMJ 2013; 346: f4247.
      • 7. Elshaug AG, Watt AM, Mundy L, Willis CD. Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012; 197: 556-560. <MJA full text>
      • 8. Maxwell S, O’Leary P, Slevin T, Moorin R. The increase in cancer prevalence and hospital burden in Western Australia 1992–2011. Popul Health Metr 2014; 12: 33.
      • 9. Treadwell J, McCartney M. Overdiagnosis and overtreatment. Br J Gen Pract 2016; 66: 116-117.
      • 10. Québec Medical Association. Overdiagnosis: findings and action plan. Québec Medical Association; 2014. www.amq.ca/images/stories/documents/m%C3%A9moires/surdiagnostic-plan-action-en.pdf (viewed Jan 2018).
      • 11. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 358: 178-190.
      • 12. Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ 2017; 358: j3879.
      • 13. Scott IA, Soon J, Elshaug A, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust 2017; 206: 407-411. <MJA full text>
      • 14. MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology 2017; 284: 228-243.
      • 15. Soon J, Buchbinder R, Close J, et al. Identifying low-value care: the Royal Australasian College of Physicians’ EVOLVE initiative. Med J Aust 2016; 204: 180-181. <MJA full text>

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        Trials and tribulations: improving outcomes for adolescents and young adults with rare and low survival cancers

        Adam Walczak, Pandora Patterson and David Thomas
        Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.00976
        Published online: 15 October 2018

        Coordinated national action is needed to develop an evidence base and standards of care for young Australians with rare and low survival cancers

        In November 2016, the Australian Senate established a select committee to explore the impact of funding models on rare and low survival cancer research. CanTeen Australia presented a submission to this inquiry which highlighted the impact of these cancers on adolescents and young adults (AYAs) and the systemic barriers to improving outcomes for patients with rare and low survival cancers. Drawing from that submission, we present the argument for a strategic national approach, including a national trial network, to facilitate cross-sectoral coordination and investment to improve outcomes for AYA patients with cancer and the broader Australian population affected by rare and low survival cancers.


        • 1 CanTeen Australia, Sydney, NSW
        • 2 Cancer Nursing Research Unit, University of Sydney, Sydney, NSW
        • 3 Kinghorn Cancer Centre, Garvan Institute of Medical Research, Sydney, NSW
        • 4 University of New South Wales, Sydney, NSW


        Correspondence: adam.walczak@canteen.org.au
        Acknowledgements: 

        We thank Peter Orchard and Kimberley Allison for their contributions to the development of this manuscript.

        Competing interests:

        CanTeen Australia received Commonwealth Government funding to support the Australian Young Cancer Patient Clinical Trials Initiative.

        • 1. Australian Institute of Health and Welfare. Cancer in adolescents and young adults in Australia (AIHW Cat. No. CAN 59; Cancer Series No. 62). Canberra: AIHW; 2011. https://www.aihw.gov.au/reports/cancer/cancer-in-adolescents-and-young-adults-in-australi/contents/table-of-contents (viewed Sept 2017).
        • 2. Bleyer A, Budd T, Montello M. Adolescents and young adults with cancer: the scope of the problem and criticality of clinical trials. Cancer 2006; 107: 1645-1655.
        • 3. Thomas DM, Seymour JF, O’Brien T, et al. Adolescent and young adult cancer: a revolution in evolution? Intern Med J 2006; 36: 302-307.
        • 4. Rare Cancers Australia. Just a little more time: rare cancers update report. Bowral, Australia: Rare Cancers Australia; 2016. https://www.rarecancers.org.au/page/1081/reports-submissions (viewed Oct 2017).
        • 5. Bleyer A. Adolescent and young adult (AYA) cancers: distinct biology, different therapy? Cancer Forum 2009; 33: 4-10.
        • 6. Tricoli JV, Blair DG, Anders CK, et al. Biologic and clinical characteristics of adolescent and young adult cancers: Acute lymphoblastic leukemia, colorectal cancer, breast cancer, melanom, and sarcoma. Cancer 2016; 122: 1017-1028.
        • 7. Bond MC, Pritchard S. Understanding clinical trials in childhood cancer. Paediatr Child Health 2006; 11: 148-150.
        • 8. Mitchell AE, Scarcella DL, Rigutto GL, et al. Cancer in adolescents and young adults: treatment and outcome in Victoria. Med J Aust 2004; 180: 59-62. <MJA full text>
        • 9. Teenage Cancer Trust. Giving more young people with cancer the opportunity to take part in clinical trials. London: Teenage Cancer Trust; 2014. https://teenagecancertrust.org/sites/default/files/Clinical%20Trials%20Paper_JR_FINAL_April15.pdf (viewed Oct 2017).
        • 10. Abrahamyan L, Feldman BM, Tomlinson G, et al. Alternative designs for clinical trials in rare diseases. Am J Med Genet C Semin Med Genet 2016; 172: 313-331.
        • 11. Tuffaha HW, Andronis L, Scuffham PA. Setting Medical Research Future Fund priorities: assessing the value of research. Med J Aust 2017; 206: 63-65. <MJA full text>
        • 12. Casali PG, Bruzzi P, Bogaerts J, Blay JY. Rare Cancers Europe (RCE) methodological recommendations for clinical studies in rare cancers: a European consensus position paper. Ann Oncol 2015; 26: 300-306.
        • 13. Augustine EF, Adams HR, Mink JW. Clinical trials in rare disease: challenges and opportunities. J Child Neurol 2013; 28: 1142-1150.
        • 14. Pfister DG. Off-label use of oncology drugs: the need for more data and then some. J Clin Oncol 2012; 30: 584-586.
        • 15. Australian Clinical Trials Alliance. Report on the activities and achievements of clinical trials networks in Australia: 2004–2014. Melbourne: National Health and Medical Research Council; 2015. https://www.australianclinicaltrials.gov.au/report-activities-achievements-clinical-trials-networks (viewed Oct 2017).
        • 16. Panageas KS. Clinical trial design for rare cancers — why a less conventional route may be required. Expert Rev Clin Pharamcol 2015; 8: 661-663.
        • 17. United States Congress. H.R.733 — Recalcitrant Cancer Research Act of 2012. 112th Congress (2011–2012). United States Congress; 2012. https://www.congress.gov/bill/112th-congress/house-bill/733 (viewed Oct 2017).

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          Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome

          Helena J Teede, Marie L Misso, Jacqueline A Boyle, Rhonda M Garad, Veryan McAllister, Linda Downes, Melanie Gibson-Helm, Roger J Hart, Luk Rombauts, Lisa Moran, Anuja Dokras, Joop Laven, Terhi Piltonen, Raymond J Rodgers, Mala Thondan, Michael F Costello and Robert J Norman, on behalf of the International PCOS Network
          Med J Aust 2018; 209 (7): . || doi: 10.5694/mja18.00656
          Published online: 1 October 2018

          Abstract

          Introduction: We have developed the first international evidence-based guideline for the diagnosis and management of polycystic ovary syndrome (PCOS), with an integrated translation program incorporating resources for health professionals and consumers. The development process involved an extensive Australian-led international and multidisciplinary collaboration of health professionals and consumers over 2 years. The guideline is approved by the National Health and Medical Research Council and aims to support both health professionals and women with PCOS in improving care, health outcomes and quality of life. A robust evaluation process will enable practice benchmarking and feedback to further inform evidence-based practice. We propose that this methodology could be used in developing and implementing guidelines for other women’s health conditions and beyond.

          Main recommendations: The recommendations cover the following broad areas: diagnosis, screening and risk assessment depending on life stage; emotional wellbeing; healthy lifestyle; pharmacological treatment for non-fertility indications; and assessment and treatment of infertility.

          Changes in management as a result of this guideline: •Diagnosis:▪when the combination of hyperandrogenism and ovulatory dysfunction is present, ultrasound examination of the ovaries is not necessary for diagnosis of PCOS in adult women;▪requires the combination of hyperandrogenism and ovulatory dysfunction in young women within 8 years of menarche, with ultrasound examination of the ovaries not recommended, owing to the overlap with normal ovarian physiology; and▪adolescents with some clinical features of PCOS, but without a clear diagnosis, should be regarded as “at risk” and receive follow-up assessment.•Screening for metabolic complications has been refined and incorporates both PCOS status and additional metabolic risk factors.•Treatment of infertility: letrozole is now first line treatment for infertility as it improves live birth rates while reducing multiple pregnancies compared with clomiphene citrate.

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          • 1 National Health and Medical Research Council Centre for Research Excellence in PCOS, Monash and Adelaide Universities, Melbourne, VIC
          • 2 Monash Centre for Health Research and Implementation, Monash Public Health and Preventive Medicine, Monash University and Monash Health, Melbourne, VIC
          • 3 Polycystic Ovary Syndrome Association of Australia, Sydney, NSW
          • 4 University of Western Australia, Perth, WA
          • 5 Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC
          • 6 Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
          • 7 Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, Netherlands
          • 8 Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Centre, Oulu University Hospital, Oulu, Finland
          • 9 Robinson Research Institute, University of Adelaide and Fertility SA, Adelaide, SA
          • 10 Harp Family Medical Centre, Melbourne, VIC
          • 11 UNSW Sydney, Sydney, NSW


          Correspondence: helena.teedee@monash.edu

          Collaborating authors: Estifanos Baye, Monash Centre for Health Research and Implementation, Melbourne; Leah Brennan, Australian Catholic University, Melbourne; Cheryce Harrison, Monash Centre for Health Research and Implementation, Melbourne; Samantha Hutchison, Monash Health Centre for Research Implementation, Melbourne; Anju Joham, Monash Centre for Health Research and Implementation, Melbourne; Louise Johnson, Victorian Assisted Reproductive Treatment Authority, Melbourne; Cailin Jordan, Genea Hollywood Fertility, Perth; Jayashri Kulkarni, Monash Alfred Psychiatry Research Centre, Melbourne; Darren Mansfield, Monash Health, Melbourne; Kate Marsh, Northside Nutrition and Dietetics, Sydney; Ben W Mol, Monash University, Melbourne; Alexia Peña, Robinson Research Institute, University of Adelaide, Adelaide; Raymond Rodgers, Robinson Research Institute, University of Adelaide, Adelaide; Jane Speight, Deakin University, Geelong; Nigel Stepto, Victoria University, Melbourne; Eliza C Tassone, Monash Centre for Health Research and Implementation, Melbourne; Angela Wan, Monash University, Melbourne; Jane Woolcock, Women’s and Children’s Hospital, Adelaide.

          Acknowledgements: 

          We gratefully acknowledge the contribution of the many women with PCOS and health professionals who guided and contributed to this work. We thank our funding, partner, engaged and collaborating organisations for their roles in prioritising topics and identifying gaps, and contributing members for guideline development, providing peer review and assisting with dissemination. We acknowledge those who independently assessed the guideline against AGREEII criteria and completed methodological review, and those within the NHMRC who managed the approval process. This guideline was approved by all members of the guideline development groups and has been approved by the NHMRC.

          Specifically, our funding, partner, collaborator and engaged organisations include:

          • The NHMRC through the funded Centre for Research Excellence in Polycystic Ovary Syndrome and the members of this Centre who coordinated this international guideline effort.

          • Our partner organisations which co-funded the guideline: the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology.

          • Our collaborating and engaged societies and consumer groups: Androgen Excess and Polycystic Ovary Syndrome Society; American Pediatric Endocrine Society; Asia Pacific Paediatric Endocrine Society; Asia Pacific Initiative on Reproduction; Australasian Paediatric Endocrine Group; Australian Diabetes Society; British Fertility Society; Canadian Society of Endocrinology and Metabolism; Dietitians Association Australia; Endocrine Society (US);Endocrine Society Australia; European Society of Endocrinology; European Society for Paediatric Endocrinology; Exercise and Sports Science Australia; Fertility Society Australia; International Society of Endocrinology; International Federation of Fertility Societies; International Federation of Gynaecology and Obstetrics; Italian Society of Gynaecology and Obstetrics; Japanese Society for Paediatric Endocrinology; Latin American Society for Paediatric Endocrinology; Nordic Federation of Societies of Obstetrics and Gynaecology; PCOS Challenge; PCOS Society of India; Paediatric Endocrine Society; Polycystic Ovary Association Australia; Royal Australasian College of Physicians; Royal Australian College of General Practitioners; Royal Australian and New Zealand College of Obstetricians and Gynaecologists; Royal College of Obstetricians and Gynaecologists (UK); South African Society of Gynaecology and Obstetrics; Verity UK; Victorian Assisted Reproductive Technology Association (VARTA).

          • Our Australian translation partners: Jean Hailes for Women’s Health and VARTA.

          Funding: The guideline and translation program was primarily funded by the NHMRC Centre for Research Excellence in PCOS grant (APP1078444) and partnership grant (APP1133084). This funding was supported by a partnership with the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine. Translation costs were supported by the NHMRC Centre for Research Excellence and partnership grant. Jean Hailes for Women’s Health funded the cost of this MJA supplement.

          Competing interests:

          Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Full details of conflicts declared across the guideline development groups are available at guideline in the register of disclosures of interest.

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            Management of inflammatory bowel disease

            Emily K Wright, Nik S Ding and Ola Niewiadomski
            Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01001
            Published online: 1 October 2018

            Summary

             

            • Australia has one of the highest incidence rates of inflammatory bowel disease (IBD) in the world.
            • Early diagnosis and treatment for IBD is critical. For Crohn disease, in particular, this may change the natural history of disease and reduce disability.
            • Faecal calprotectin is a sensitive test that can be used by primary care physicians to assist in determining which patients with gastrointestinal symptoms may have IBD. This allows for prompt identification of patients who may benefit from endoscopy.
            • Regular re-evaluation of disease status with strategies that can safely, readily and reliably detect the presence of inflammation with faecal biomarkers and imaging is important. To avoid the risks of cumulative radiation exposure, magnetic resonance imaging and/or intestinal ultrasound, rather than computed tomography scanning, should be performed when possible.
            • Drug treatments for IBD now include five biological drugs listed by the Pharmaceutical Benefits Scheme: adalimumab, infliximab, golimumab, vedolizumab and ustekinumab. Such developments offer the possibility for improved disease control in selected patients.

             


            • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
            • 2 Box Hill Hospital, Melbourne, VIC


            Correspondence: Emily.Wright@svha.org.au
            Competing interests:

            No relevant disclosures.

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            • 14. van Rheenen PF, Van de Vijver E, Fidler V. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: diagnostic meta-analysis. BMJ 2010; 341: c3369.
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            • 19. Sutherland L, Macdonald JK. Oral 5-aminosalicylic acid for induction of remission in ulcerative colitis. Cochrane Database Syst Rev 2006; (2): CD000543.
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            • 23. Ford AC, Khan KJ, Talley NJ, Moayyedi P. 5-Aminosalicylates prevent relapse of Crohn’s disease after surgically induced remission: systematic review and meta-analysis. Am J Gastroenterol 2011; 106: 413-420.
            • 24. Lichtenstein GR, Abreu MT, Cohen R, Tremaine W; American Gastroenterological Association. American Gastroenterological Association Institute technical review on corticosteroids, immunomodulators, and infliximab in inflammatory bowel disease. Gastroenterology 2006; 130: 940-987.
            • 25. Lakatos PL, Golovics PA, David G, et al. Has there been a change in the natural history of Crohn’s disease? Surgical rates and medical management in a population-based inception cohort from Western Hungary between 1977–2009. Am J Gastroenterol 2012; 107: 579-588.
            • 26. Feagan BG, Rochon J, Fedorak RN, et al. Methotrexate for the treatment of Crohn’s disease. The North American Crohn’s Study Group Investigators. N Engl J Med 1995; 332: 292-297.
            • 27. Herfarth HH, Osterman MT, Isaacs KL, et al. Efficacy of methotrexate in ulcerative colitis: failure or promise. Inflamm Bowel Dis 2010; 16: 1421-1430.
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            • 29. Ariyaratnam J, Subramanian V. Association between thiopurine use and nonmelanoma skin cancers in patients with inflammatory bowel disease: a meta-analysis. Am J Gastroenterol 2014; 109: 163-169.
            • 30. Siegel CA. Review article: explaining risks of inflammatory bowel disease therapy to patients. Aliment Pharmacol Ther 2011; 33: 23-32.
            • 31. D’Haens G, Baert F, van Assche G, et al. Early combined immunosuppression or conventional management in patients with newly diagnosed Crohn’s disease: an open randomised trial. Lancet 2008; 371: 660-667.
            • 32. Colombel JF, Sandborn WJ, Reinisch W, et al. Infliximab, azathioprine, or combination therapy for Crohn’s disease. N Engl J Med 2010; 362: 1383-1395.
            • 33. Panaccione R, Ghosh S, Middleton S, et al. Combination therapy with infliximab and azathioprine is superior to monotherapy with either agent in ulcerative colitis. Gastroenterology 2014; 146: 392-400.e3.
            • 34. Croft A, Walsh A, Doecke J, et al. Outcomes of salvage therapy for steroid-refractory acute severe ulcerative colitis: ciclosporin vs. infliximab. Aliment Pharmacol Ther 2013; 38: 294-302.
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            • 36. Dave M, Purohit T, Razonable R, Loftus EV. Opportunistic infections due to inflammatory bowel disease therapy. Inflamm Bowel Dis 2014; 20: 196-212.
            • 37. Kotlyar DS, Osterman MT, Diamond RH, et al. A systematic review of factors that contribute to hepatosplenic T-cell lymphoma in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2011; 9: 36-41.e1.
            • 38. Raaschou P, Simard JF, Holmqvist M, Askling J; ARTIS Study Group. Rheumatoid arthritis, anti-tumour necrosis factor therapy, and risk of malignant melanoma: nationwide population based prospective cohort study from Sweden. BMJ 2013; 346: f1939.
            • 39. Fidder H, Schnitzler F, Ferrante M, et al. Long-term safety of infliximab for the treatment of inflammatory bowel disease: a single-centre cohort study. Gut 2009; 58: 501-508.
            • 40. Sandborn WJ, Feagan BG, Rutgeerts P, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2013; 369: 711-721.
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            • 42. Feagan BG, Sandborn WJ, Gasink C, et al. Ustekinumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med 2016; 375: 1946-1960.
            • 43. Ma C, Fedorak RN, Kaplan GG, et al. Long-term maintenance of clinical, endoscopic, and radiographic response to ustekinumab in moderate-to-severe Crohn’s disease: real-world experience from a multicenter cohort study. Inflamm Bowel Dis 2017; 23: 833-839.
            • 44. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013; 368: 407-415.
            • 45. Paramsothy S, Kamm MA, Kaakoush NO, et al. Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial. Lancet 2017; 389: 1218-1228.
            • 46. Costello SP, Soo W, Bryant RV, et al. Systematic review with meta-analysis: faecal microbiota transplantation for the induction of remission for active ulcerative colitis. Aliment Pharmacol Ther 2017; 46: 213-224.
            • 47. Graff LA, Walker JR, Bernstein CN. Depression and anxiety in inflammatory bowel disease: a review of comorbidity and management. Inflamm Bowel Dis 2009; 15: 1105-1118.
            • 48. Rahier JF, Magro F, Abreu C, et al. Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease. J Crohns Colitis 2014; 8: 443-468.
            • 49. Sigall-Boneh R, Pfeffer-Gik T, Segal I, et al. Partial enteral nutrition with a Crohn’s disease exclusion diet is effective for induction of remission in children and young adults with Crohn’s disease. Inflamm Bowel Dis 2014; 20: 1353-1360.
            • 50. Lindberg E, Järnerot G, Huitfeldt B. Smoking in Crohn’s disease: effect on localisation and clinical course. Gut 1992; 33: 779-782.

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              A new evidence-based guideline for assessment and management of polycystic ovary syndrome

              Robert J Norman and Helena J Teede
              Med J Aust 2018; 209 (7): . || doi: 10.5694/mja18.00635
              Published online: 1 October 2018

              An Australian-led international and multidisciplinary collaboration has developed new recommendations to improve the care, health outcomes and quality of life of women with PCOS

              Polycystic ovary syndrome (PCOS) is one of the most common hormonal conditions in women of reproductive age and often presents in adolescence with further manifestation in later reproductive life.1 Many women are not diagnosed or have long delays before the condition is recognised.2 Key patient needs are not being met well, and knowledge gaps have been shown in both patients and health professionals alike.2,3 This is of particular concern in a condition where the prevalence is generally considered to be between 9% and 18%, depending on the definition and the population studied.4


              • 1 Robinson Research Institute, University of Adelaide, Adelaide, SA
              • 2 Fertility SA, Adelaide, SA
              • 3 Monash Partners Academic Health Sciences Centre, Monash University, Melbourne, VIC


              Acknowledgements: 

              The Centre of Research Excellence in PCOS is funded by the National Health and Medical Research Council.

              Competing interests:

              We are co-authors of the International evidence-based guideline for the assessment and management of polycystic ovary syndrome.

              • 1. Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet 2007; 370: 685-697.
              • 2. Gibson-Helm M, Teede H, Dunaif A, Dokras A. Delayed diagnosis and a lack of information associated with dissatisfaction in women with polycystic ovary syndrome. J Clin Endocrinol Metab 2017; 102: 604-612.
              • 3. Tata B, Mimouni NEH, Barbotin AL, et al. Elevated prenatal anti-Mullerian hormone reprograms the fetus and induces polycystic ovary syndrome in adulthood. Nat Med 2018; 24: 834-846.
              • 4. Balen AH, Morley LC, Misso M, et al. The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance. Hum Reprod Update 2016; 22: 687-708.
              • 5. Teede HJ, Misso ML, Deeks AA, et al. Assessment and management of polycystic ovary syndrome: summary of an evidence-based guideline. Med J Aust 2011; 195 (6 Suppl): S65-S110. <MJA full text>
              • 6. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril 2018; 110: 364-379.
              • 7. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod 2018; doi: 10.1093/humrep/dey256 [Epub ahead of print].
              • 8. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol (Oxf) 2018; doi: 10.1111/cen.13795 [Epub ahead of print].
              • 9. Teede HJ, Misso ML, Boyle JA, et al. Translation and implementation of the Australian-led PCOS guideline: clinical summary and translation resources from the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Med J Aust 2018; 209 (7 Suppl): S1-S23.
              • 10. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004; 81: 19-25.
              • 11. Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update 2010; 16: 347-363.
              • 12. Dokras A, Stener-Victorin E, Yildiz BO, et al. Androgen Excess- Polycystic Ovary Syndrome Society: position statement on depression, anxiety, quality of life, and eating disorders in polycystic ovary syndrome. Fertil Steril 2018; 109: 888-899.

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                Pathway to ending avoidable diabetes-related amputations in Australia

                Peter A Lazzarini, Jaap J van Netten, Robert A Fitridge, Ian Griffiths, Ewan M Kinnear, Matthew Malone, Byron M Perrin, Jenny Prentice and Paul R Wraight
                Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01198
                Published online: 1 October 2018

                A new Australian strategy should finally reduce the significant national burden of diabetes-related foot disease

                Diabetes-related foot disease (DFD) is “common, complex, and costly”1 and underappreciated in Australia.2 With DFD not even rating a footnote mention in recent national chronic disease strategies,3 it is arguably Australia’s least known major health problem.2 If Australia is to reduce avoidable amputations, major improvements in the way we approach DFD are urgently needed.2,4


                • 1 Queensland University of Technology, Brisbane, QLD
                • 2 Metro North Hospital and Health Service, Brisbane, QLD
                • 3 Amsterdam Movement Sciences, Academic Medical Center, Amsterdam, Netherlands
                • 4 Royal Adelaide Hospital, Adelaide, SA
                • 5 Wound Management Innovation Cooperative Research Centre, Brisbane, QLD
                • 6 Liverpool Hospital, Sydney, NSW
                • 7 La Trobe Rural Health School, La Trobe University, Bendigo, VIC
                • 8 Royal Melbourne Hospital, Melbourne, VIC


                Acknowledgements: 

                Diabetic Foot Australia is kindly supported by grant funding from the Wound Management Innovation Cooperative Research Centre.

                Competing interests:

                We are all authors of the Australian Diabetes-related Foot Disease Strategy 2018–2022, and members of the steering committee of the Diabetic Foot Australia Wound Management Innovation Cooperative Research Centre.

                • 1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017; 376: 2367-2375.
                • 2. Lazzarini PA, Gurr JM, Rogers JR, et al. Diabetes foot disease: the Cinderella of Australian diabetes management? J Foot Ankle Res 2012; 5: 24.
                • 3. Australian Government Department of Health. Australian National Diabetes Strategy 2016–2020. Canberra: Commonwealth of Australia, 2015. http://www.health.gov.au/internet/main/publishing.nsf/content/nds-2016-2020 (viewed Dec 2017).
                • 4. Van Netten JJ, Lazzarini PA, Fitridge R, et al. Australian diabetes-related foot disease strategy 2018–2022: the first step towards ending avoidable amputations within a generation. Brisbane: Diabetic Foot Australia, 2017. https://www.diabeticfootaustralia.org/for-researchers/australian-diabetes-related-foot-disease-strategy-2018-2022/ (viewed Dec 2017).
                • 5. Australian Commission on Safety and Quality in Health Care. The first Australian atlas of healthcare variation. Sydney: ACSQHC, 2015. https://www.safetyandquality.gov.au/atlas/atlas-2015/ (viewed Aug 2018).
                • 6. Lazzarini PA. The burden of foot disease in inpatient populations [PhD thesis]. Brisbane: Queensland University of Technology, 2016. https://eprints.qut.edu.au/101526/ (viewed Dec 2017).
                • 7. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2016; 13: 892-903.
                • 8. West M, Chuter V, Munteanu S, Hawke F. Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians. J Foot Ankle Res 2017; 10: 48.
                • 9. Schaper NC, Van Netten JJ, Apelqvist J, et al. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev 2016; 32: 7-15.
                • 10. National evidence-based guideline for the prevention, identification and management of foot complications in diabetes (part of the guidelines on management of type 2 diabetes). Melbourne: Baker IDI Heart and Diabetes Institute, 2011. http://t2dgr.bakeridi.edu.au/ (viewed Dec 2017).
                • 11. Morbach S, Kersken J, Lobmann R, et al. The German and Belgian accreditation models for diabetic foot services. Diabetes Metab Res Rev 2016; 32: 318-325.
                • 12. Bergin SM, Alford JB, Allard BP, et al. A limb lost every 3 hours: can Australia reduce amputations in people with diabetes? Med J Aust 2012; 197: 197-198. <MJA full text>
                • 13. Lazzarini PA, O’Rourke SR, Russell AW, et al. Reduced incidence of foot-related hospitalisation and amputation amongst persons with diabetes in Queensland, Australia. PLoS ONE 2015; 10: e0130609.
                • 14. Cheng Q, Lazzarini PA, Gibb M, et al. A cost-effectiveness analysis of optimal care for diabetic foot ulcers in Australia. Int Wound J 2017; 14: 616-628.
                • 15. van Netten JJ, Baba M, Lazzarini PA. Epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia: a systematic review protocol. Syst Rev 2017; 6: 101.

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                  Medical assistance in dying: a disruption of therapeutic relationships

                  Leeroy William
                  Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01217
                  Published online: 1 October 2018

                  Medical assistance in dying may disrupt therapeutic relationships and will challenge beliefs

                  Medical assistance in dying, whether voluntary euthanasia or physician-assisted suicide, has been a recurring topic for societal debate. Voluntary euthanasia is the deliberate and intentional act to end a competent person’s life, at their request, to relieve their suffering.1 Physician-assisted suicide relates to the medical provision of the means or knowledge for someone to commit suicide via the self-administration of a prescribed medication.1 Amid growing societal support2 and stability of worldwide medical opinion, there has been a 66% increase in the legalisation of physician-assisted suicide since 2015,3 which indirectly legitimises such practices through the broad influence it has on societal support. Canada and the American states of California and Colorado legalised physician-assisted suicide in 2016.3 In Australia, the Victorian Parliament passed a Bill in 2017 to legalise physician-assisted suicide, while the debate currently continues in other Australian states and New Zealand. By contrast, in May 2018 Guernsey failed to become the first place in Britain to permit physician-assisted suicide.4


                  • 1 Eastern Health, Melbourne, VIC
                  • 2 Monash University, Melbourne, VIC


                  Correspondence: leeroy.william@monash.edu
                  Competing interests:

                  No relevant disclosures.

                  • 1. Queensland University of Technology. End of life law in Australia. Euthanasia and assisted dying. https://end-of-life.qut.edu.au/euthanasia#547411 (accessed Aug 2018).
                  • 2. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA 2016; 316: 79-90.
                  • 3. Kennedy Institute of Ethics, Georgetown University. Euthanasia regulations around the world. https://ethicslab.georgetown.edu/euthanasia-map/ (accessed Aug 2018).
                  • 4. Sherwood H. Guernsey parliament votes against assisted dying. The Guardian 2018; 18 May. https://www.theguardian.com/society/2018/may/18/guernsey-parliament-votes-against-assisted-dying (accessed Aug 2018).
                  • 5. Hendry M, Pasterfield D, Lewis R, et al. Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying. Palliat Med 2012; 27: 13-26.
                  • 6. Kelly BJ, Varghese FT, Pelusi D. Countertransference and ethics: a perspective on clinical dilemmas in end-of-life decisions. Palliat Support Care 2003; 1: 367-375.
                  • 7. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 390: 178-190.
                  • 8. Estacio CF, Butow PN, Lovell MR, et al. Exploring symptom meaning: perspectives of palliative care physicians. Support Care Cancer 2018; 26: 2769-2784.
                  • 9. Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd ed. New York, Oxford: Oxford University Press, 1989.
                  • 10. Working Party of the Royal College of Physicians. Doctors in society: medical professionalism in a changing world. Clin Med (Lond) 2005; 5 (6 Suppl 1): S5-S40.
                  • 11. Bergman YS, Bodner E, Haber Y. The connection between subjective nearness-to-death and depressive symptoms: the mediating role of meaning in life. Psychiatry Res 2018; 261: 269-273.
                  • 12. McKenzie EL, Brown PM, Mak AS, Chamberlain P. “Old and ill”: death anxiety and coping strategies influencing health professionals’ well-being and dementia care. Aging Ment Health 2017; 21: 634-641.
                  • 13. Belmi P, Pfeffer J. Power and death: mortality salience increases power seeking while feeling powerful reduces death anxiety. J Appl Psychol 2016; 101: 702-720.
                  • 14. Virdun C, Luckett T, Lorenz K, et al. Dying in the hospital setting: a meta-synthesis identifying the elements of end-of-life care that patients and their families describe as being important. Palliat Med 2017; 31: 587-601.
                  • 15. Smith C, Bosanquet N, Riley J, Koffman J. Loss, transition and trust: perspectives of terminally ill patients and their oncologists when transferring care from the hospital into the community at the end of life. BMJ Support Palliat Care 2016; doi: 10.1136/bmjspcare-2015-001075.
                  • 16. Wong PTP, Reker GT, Gesser G. Death attitude profile-revised: a multidimensional measure of attitudes toward death. In: Neimeyer RA. Death anxiety handbook: research, instrumentation, and application. Washington DC: Taylor & Francis, 1994.
                  • 17. Thiemann P, Quince T, Benson J, et al. Medical students’ death anxiety: severity and association with psychological health and attitudes toward palliative care. J Pain Symptom Manage 2015; 50: 335-342.

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                    Surveillance improves survival of patients with hepatocellular carcinoma: a prospective population-based study

                    Thai P Hong, Paul J Gow, Michael Fink, Anouk Dev, Stuart K Roberts, Amanda Nicoll, John S Lubel, Ian Kronborg, Niranjan Arachchi, Marno Ryan, William W Kemp, Virginia Knight, Vijaya Sundararajan, Paul Desmond, Alexander JV Thompson and Sally J Bell
                    Med J Aust 2018; 209 (8): . || doi: 10.5694/mja18.00373
                    Published online: 24 September 2018

                    Abstract

                    Objectives: To determine the factors associated with survival of patients with hepatocellular carcinoma (HCC) and the effect of HCC surveillance on survival.

                    Design, setting and participants: Prospective population-based cohort study of patients newly diagnosed with HCC in seven tertiary hospitals in Melbourne, 1 July 2012 – 30 June 2013.

                    Main outcome measures: Overall survival (maximum follow-up, 24 months); factors associated with HCC surveillance participation and survival.

                    Results: 272 people were diagnosed with incident HCC during the study period; the most common risk factors were hepatitis C virus infection (41%), alcohol-related liver disease (39%), and hepatitis B virus infection (22%). Only 40% of patients participated in HCC surveillance at the time of diagnosis; participation was significantly higher among patients with smaller median tumour size (participants, 2.8 cm; non-participants, 6.0 cm; P < 0.001) and earlier Barcelona Clinic Liver Cancer (BCLC) stage disease (A/B, 59%; C/D, 25%; P < 0.001). Participation was higher among patients with compensated cirrhosis or hepatitis C infections; it was lower among those with alcohol-related liver disease or decompensated liver disease. Median overall survival time was 20.8 months; mean survival time was 18.1 months (95% CI, 16.6–19.6 months). Participation in HCC surveillance was associated with significantly lower mortality (adjusted hazard ratio [aHR], 0.60; 95% CI, 0.38–0.93; P = 0.021), as were curative therapies (aHR, 0.33; 95% CI, 0.19–0.58). Conversely, higher Child–Pugh class, alpha-fetoprotein levels over 400 kU/L, and later BCLC disease stages were each associated with higher mortality.

                    Conclusions: Survival for patients with HCC is poor, but may be improved by surveillance, associated with the identification of earlier stage tumours, enabling curative therapies to be initiated.

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                    • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
                    • 2 Austin Hospital, Melbourne, VIC
                    • 3 University of Melbourne, Melbourne, VIC
                    • 4 Austin Health, Melbourne, VIC
                    • 5 Monash Health, Melbourne, VIC
                    • 6 Eastern Health, Melbourne, VIC
                    • 7 Western Health, Melbourne, VIC
                    • 8 Alfred Hospital, Melbourne, VIC


                    Correspondence: thai.hong@svha.org.au
                    Competing interests:

                    No relevant disclosures.

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                      Helicobacter pylori infection and the risk of upper gastrointestinal bleeding in low dose aspirin users: systematic review and meta-analysis

                      Justin CH Ng and Neville David Yeomans
                      Med J Aust 2018; 209 (7): . || doi: 10.5694/mja17.01274
                      Published online: 24 September 2018

                      Abstract

                      Objective: To determine whether the risk of upper gastrointestinal bleeding in patients taking low dose aspirin (≤ 325 mg/day) is increased in people with Helicobacter pylori infections.

                      Study design: A systematic search for all publications since 1989 (when H. pylori was named) using search term equivalents for “upper gastrointestinal haemorrhage” and “aspirin”. Articles were assessed individually for inclusion of data on H. pylori infection, as not all relevant papers were indexed with this term. Data that could be pooled were then subjected to meta-analysis, using a random effects model.

                      Data sources: MEDLINE, Embase, Scopus, the Cochrane Library.

                      Data synthesis: Of 7599 retrieved publications, reports for seven case–control studies contained data suitable for meta-analysis; four were deemed high quality on the Newcastle–Ottawa scale. Upper gastrointestinal haemorrhage was more frequent in aspirin users infected with H. pylori than in those who were not (odds ratio [OR], 2.32; 95% CI, 1.25–4.33; P = 0.008). The heterogeneity of the studies was significant (Q = 19.3, P = 0.004; I2 = 68.9%, 95% CI, 31.5–85.9%), but the pooled odds ratio was similar after removing the two studies that contributed most to heterogeneity (OR, 2.34; 95% CI, 1.56–3.53; P < 0.001). The number needed to treat to prevent one bleeding event annually was estimated to be between 100 and more than 1000.

                      Conclusions: The odds of upper gastrointestinal bleeding in patients taking low dose aspirin is about twice as great in those infected with H. pylori. Testing for and treating the infection should be considered in such patients, especially if their underlying risk of peptic ulcer bleeding is already high.


                      • 1 University of Melbourne, Melbourne, VIC
                      • 2 Peninsula Health, Melbourne, VIC
                      • 3 Austin Health, Melbourne, VIC


                      Correspondence: JNg@phcn.vic.gov.au
                      Acknowledgements: 

                      We thank Helen Baxter and Shanti Nadaraja (Austin Health Sciences Library, Austin Health) for expert assistance with the structured literature searches.

                      Competing interests:

                      No relevant disclosures.

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